Quality management in medical rehabilitative care by the German statutory pension insurance scheme.

This paper aims to provide an insight into the quality management approach for medical rehabilitation services of the German statutory pension insurance scheme. In the 1990s, the German statutory pension insurance scheme initiated a quality management programme in rehabilitation, which is subject to continuous development. The main objective of implementing quality management in rehabilitative care was quality control and quality improvement. To achieve these goals, five main tools for quality measurements were applied: a classification of therapeutic services, standards of rehabilitative interventions, patient surveys, peer review, and surveys that address structure of care. These tools enable the assessment of the structural and process quality of rehabilitative care, as well as aspects of rehabilitation outcome. As a result, quality of rehabilitation care becomes more measurable, transparent, and hence can be improved on well-founded grounds. These measurements allow implementing comparisons and benchmarking of rehabilitation facilities, thereby creating incentives for quality improvements. Therefore, the development and implementation of quality management measures in facilities of inpatient and outpatient medical rehabilitation is an ongoing process and expands to other areas of rehabilitation.

Generating evidence and understanding the treatment of osteoarthritis in Brazil: a study through Delphi methodology

OBJECTIVES: This study aimed to provide evidence for understanding how to treat osteoarthritis (OA) in our country. Therefore, it was necessary to match information and investigations related to the treatment of the disease from the three main types of specialists involved: physiatrists, orthopedists and rheumatologists. METHODS: The authors acted as a scientific advisory committee. From the initial discussions, a structured questionnaire was developed for use with a group of specialists on OA using the Delphi technique. The questionnaire was sent to 21 experts appointed by the authors, and the results obtained were critically analyzed and validated. RESULTS: The prevalence of OA was 33% in Brazil, corresponding to one-third of the individuals in the reference population, which included individuals over 25 years of age. Another significant finding was that most patients did not receive any form of treatment in the early stages of OA. CONCLUSION: The committee pointed to the need for early intervention and that the available medicinal resources can fulfil this important role, as is the case with SYSADOA treatments. Glucosamine-based medicinal products with or without chondroitin could also fulfill this need for early treatment. The other generated evidence and included investigations were then grouped together and are the subject of this publication.

Rehabilitation for Cancer Survivors: How We Can Reduce the Healthcare Service Inequality in Low- and Middle-Income Countries.

Cancer diagnosis often substantially affects patient's physical, psychological, and emotional status. Most patients with cancer experience declining of energy, activity levels, social-cultural participation, and relationships. In addition, cancer progression and adverse effects of aggressive cancer treatment often cause debilitating pain, fatigue, weakness, joint stiffness, depression, emotional instability, limited mobility, poor nutritional status, skin breakdown, bowel dysfunction, swallowing difficulty, and lymphedema leading into functional impairment and disability that can be addressed through rehabilitation care. Comprehensive care models by involving cancer rehabilitation have resulted in significant improvement of patient's quality of life. Although cancer rehabilitation has been implemented in many high-income countries, it is either not yet or suboptimally delivered in most low- and middle-income countries. In this review, we discussed gaps regarding cancer rehabilitation services and identified opportunities to improve quality of cancer care in developing countries. Future collaborations among international organizations and stakeholders of health care delivery systems are required to initiate and improve high-quality cancer rehabilitation in the developing countries.

International Classification of Functioning, Disability and Health (ICF) - way to Health Promotion / A Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) - um caminho para a Promoção da Saúde

Abstract The International Classification of Functioning, Disability and Health (ICF) is a classification of the World Health Organization (WHO). It is a reference document for the description of phenomena related to functioning and disability. The aim of the present study is to assess the relationship between the theoretical assumptions of ICF and the field of Health Promotion. The dissemination of ICF has been widely documented in literature over the last few years, however, there is a large gap between enthusiasm with the paradigm change that the classification proposes and its effective incorporation in the different environments of health care. This study presents an example of ICF operation-alization. The biopsychosocial evaluation model of ICF presented is a strategy of light technology in health that advances towards the proposals of the field of Health Promotion.

Resumo A Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF) é uma classificação da Organização Mundial de Saúde (OMS). É um documento de referência para a descrição de fenômenos relacionados a funcionalidade e incapacidade. O objetivo do presente trabalho é traçar uma relação entre os pressupostos teóricos da CIF com o campo da Promoção da Saúde. A disseminação da CIF tem sido amplamente documentada na literatura ao longo dos últimos anos, no entanto, há uma grande lacuna entre o entusiasmo com a mudança de paradigma que a classificação propõe e sua efetiva incorporação nos diferentes ambientes do cuidado em saúde. O presente ponto de vista apresenta um exemplo de operacionalização da CIF. O modelo de avaliação biopsicossocial da CIF apresentado é uma estratégia de tecnologia leve em saúde que caminha para o avanço das propostas do campo da Promoção da Saúde.

Femoral cartilage thickness measurements in healthy individuals: learning, practicing and publishing with TURK-MUSCULUS.

BACKGROUND AND OBJECTIVES: Measurement of the femoral cartilage thickness by using in-vivo musculoskeletal ultrasonography (MSUS) has been previously shown to be a valid and reliable method in previous studies; however, to our best notice, normative data has not been provided before in the healthy population.The aim of our study was to provide normative data regarding femoral cartilage thicknesses of healthy individuals with collaborative use of MSUS. METHODS: This is across-sectional study run at Physical and Rehabilitation Medicine Departments of 18 Secondary and Tertiary Centers in Turkey. 1544 healthy volunteers (aged between 25-40 years) were recruited within the collaboration of TURK-MUSCULUS (Turkish Musculoskeletal Ultrasonography Study Group). Subjects who had a body mass index value of less than 30 and who did not have signs and symptoms of any degenerative/inflammatory arthritis or other rheumatic diseases, history of knee trauma and previous knee surgery were enrolled. Ultrasonographic measurements were performed axially from the suprapatellar window by using linear probes while subjects' knees were in maximum flexion. Three (mid-point) measurements were taken from both knees (lateral condyle, intercondylar area, medial condyle). RESULTS: A total of 2876 knees (of 817 M, 621 F subjects) were taken into analysis after exclusion of inappropriate images. Mean cartilage thicknesses were significantly lower in females than males (all p< 0.001). Thickness values negatively correlated with age; negatively (females) and positively (males) correlated with smoking. Men who regularly exercised had thicker cartilage than who did not exercise (all p < 0.05). Increased age (in both sexes) and absence of exercise (males) were found to be risk factors for decreased cartilage thicknesses. CONCLUSION: Further data pertaining to other countries would be interesting to uncover whether ethnic differences also affect cartilage thickness. Collaborative use of MSUS seems to be promising in this regard.

Generalised and regional soft tissue pain syndromes. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of PRM interventions. Generalised and regional soft tissue pain syndromes constitute a major problem leading to loss of function and disability, resulting in enormous societal burden. The aim of this paper is to describe the unique role of PRM physicians in the management of these disabling conditions that require not only pharmacological interventions but also a holistic approach including the consideration of body functions, activities and participation as well as contextual factors as described in the ICF. Evidence-based effective PRM interventions include exercise and multicomponent treatment including a psychotherapeutic intervention such as cognitive behavioural therapy (CBT) in addition to exercise, the latter based on strong evidence for reducing pain and improving quality of life in fibromyalgia syndrome (FMS). Balneotherapy, meditative movement therapies, and acupuncture have also been shown as efficacious in improving symptoms in FMS. Emerging evidence suggests the use of transcranial magnetic or direct current stimulation (rTMS or tDCS) in FMS patients with intractable pain not alleviated by other interventions. Graded exercise therapy and CBT are evidence-based options for chronic fatigue syndrome. The use of some physical modalities and manipulation for myofascial pain syndrome is also supported by evidence. As for complex regional pain syndrome (CRPS), strong evidence exists for rTMS and graded motor imagery as well as moderate evidence for mirror therapy. Interventional techniques such as blocks and spinal cord stimulation may also be considered for CRPS based on varying levels of evidence. PRM physicians' functioning oriented approaches on the assessment and management, adopting the ICF as a reference, may well meet the needs of patients with soft tissue pain syndromes, the common problems for whom are loss of function and impaired quality of life. Available evidence for the effectiveness of PRM interventions serves as the basis for the explicit role of PRM specialists in the management of these health conditions.

Systematic reviews of physical and rehabilitation medicine Cochrane contents. Part 1. Disabilities due to spinal disorders and pain syndromes in adults.

BACKGROUND: This article is the first in a series presenting the strongest published evidence for physical and rehabilitation medicine (PRM) to date coming from the Cochrane Collaboration. The intent of the series is to stimulate ideas for reviews and research in neglected areas of PRM. AIM: To systematically review the rehabilitation contents of the Cochrane Collaboration on disabilities due to spinal disorders or pain syndromes in adults. METHODS: The Cochrane Database of Systematic Reviews was searched at the end of June 2013 for articles relevant for PRM about disabilities resulting from spinal disorders or pain syndromes in adults. Retrieved papers were classified according to the PRM approach: active therapies, which require active participation by patients to achieve treatment goals, and passive treatments, which rely on the application of external forces. The quality of the reviews was checked against the AMSTAR checklist. RESULTS: Reviews on spinal disorders or pain syndromes were found in the Cochrane Back Group (CBG) and in the Pain, Palliative and Supportive Care Group (CPPSCG). Thirty-eight (42.8%) of 89 Cochrane reviews in the CBG and 7 (2.4%) of 293 Cochrane reviews in the CPPSCG were included. All were of high quality (range, 8-11 points out of 11 on the AMSTAR checklist). The contents of the reviews are given in detail. CONCLUSION: This review presents an overview of the current evidence for PRM in the treatment of disabilities due to spinal disorders or pain syndromes in adults. Within PRM there is ample space for research in the Cochrane Collaboration and for producing original studies (randomized controlled trials [RCTs]). CLINICAL REHABILITATION IMPACT: To apply evidence-based clinical practice, clinicians must be familiar with the current best evidence.

Musculoskeletal perioperative problems. The role of physical and rehabilitation medicine physicians. The European perspective based on the best evidence. A paper by the UEMS-PRM Section Professional Practice Committee.

One of the objectives of the Professional Practice Committee (PPC) of the Physical and Rehabilitation Medicine (PRM) Section of the Union of European Medical Specialists (UEMS) is the development of the field of competence of PRM physicians in Europe. To achieve this objective, UEMS PRM Section PPC has adopted a systematic action plan of preparing a series of papers describing the role of PRM physicians in a number of disabling health conditions, based on the evidence of effectiveness of the physical and rehabilitation medicine interventions. According to the UEMS-PRM section, the role of PRM physician in musculoskeletal perioperative settings has to be situated inside general pain management. Musculoskeletal surgery (MSS) represents a frequent medical situation among patients suffering from musculoskeletal disorders (MSDs), in which PRM physicians need to be involved. A wide number of MSDs have to be operated in order to diminish disability and relieve symptoms, thus improving the patient´s functioning and social participation: Joint replacements, spine decompressions, vertebroplasties, internal fixation of unstable fractures, arthroscopies for tendon and joint repairs, and others. This paper describes the role of the PRM physician during the perioperative period. A well-coordinated rehabilitation programme followed by a good home rehabilitation programme results in pain reduction, faster recovery with better patient participation and increased cost effectiveness. PRM physicians have to identify patients at risk of continuing activity limitation and participation restriction who will benefit from an early rehabilitation process and formulate a PRM programme of care taking into account each patient's environmental factors.

Establishing recommendations for physical medicine and rehabilitation: the SOFMER methodology.

OBJECTIVE: The development of a rigorous methodology based on published results of clinical trials, evaluation of daily practice in France and multidisciplinary expert opinion to elaborate recommendations for rehabilitation interventions. METHODS AND RESULTS: The following describes the methodology of SOFMER (Société Française de Médecine Physique et de Réadaptation [French Society of Physical Medicine and Rehabilitation]) for developing recommendations for rehabilitation interventions. The test case was developing recommendations for rehabilitation in hip or knee osteoarthritis (OA) and hip or knee arthroplasty. Physicians in rehabilitation, orthopedic surgery and rheumatology identified, synthesized, and analyzed data from the literature by use of the usual French system of grading trials (the French Agency for Accreditation and Evaluation in Healthcare [ANAES] scale). The data were published results of comparative controlled studies such as randomized controlled trials, controlled clinical trials, cohort studies, case control studies, reviews of clinical trials, and case series, as well as uncontrolled cohort studies. The resulting recommendations were presented to the three annual French national congresses of rehabilitation, rheumatology, and orthopedic surgery for comment and for adapting to French professional practice. Finally, a panel of multidisciplinary experts (physicians in physical medicine and rehabilitation, rheumatologists, orthopedic surgeons, general practitioners, physical therapists, social workers, podologists, occupational therapists, nurses, and patients) validated the recommendations. CONCLUSION: The SOFMER methodology could be an interesting tool for use in developing recommendations elaborated by all the concerned medical and surgical specialists in the wide domain of rehabilitation.

Issues in the development of an item bank.

OBJECTIVE: To describe and illustrate 2 issues involved in the development of an item bank that can be used to improve measurement across settings and over time. DESIGN: Secondary (psychometric) analysis of data collected on existing quality of life (QOL) instruments. SETTING: Five cancer clinics in hospital settings in various parts of the United States; 523 solo or group practices in 3 major US cities; and an inpatient rehabilitation hospital in a large metropolitan area. PARTICIPANTS: Illustration 1: 399 persons being treated for or having a history of cancer, 170 persons being treated for human immunodeficiency virus (HIV), 328 persons with stroke assessed during and after acute rehabilitation, and 433 persons being treated for multiple sclerosis. Illustration 2: 1714 persons with cancer and/or HIV participating in a large-scale multisite study, 3429 persons with prevalent treatable chronic health conditions, and 125 persons with stage IV metastatic breast cancer. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: QOL as measured by 10 different instruments. RESULTS: The illustrations show that (1). core items, which functioned similarly across 4 diagnostic groups, can be identified and used to construct instruments measuring physical function that are tailored to each of these groups, and (2). items from 3 separate datasets can be linked to create a dataset that can serve as an initial pain item bank. CONCLUSION: The methodology exists to develop item banks to develop better measures of QOL.

Evaluación de la aptitud clínica de médicos residentes de medicina física y rehabilitación / Clinical aptitude of residents of physical medicine and rehabilitation

Se informan las complicaciones postoperatorias observadas en un grupo de 27 pacientes sometidos a esplenectomía electiva por padecimientos hematológicos: 21 tuvieron padecimientos hematológicos benignos, en tanto que seis tuvieron algunas hemopatía maligna. Se presentaron siete complicaciones en seis pacientes (2 abscesos de la herida quirúrgica, 2 sangrados graves postoperatorios, una sepsis por bacterias capsuladas, una hernia post-incisional y un síndrome hemofagocítico). El índice de complicaciones fue de 27 por ciento y el de complicaciones ocurrieron en el 83 por ciento de los pacientes con hemopatías malignas y en el 9 por ciento de aquéllos con hemopatías benignas (p<.01). El tamaño del bazo tuvo relación con las complicaciones: la mediana del peso del bazo fue 990 gramos en los pacientes que se complicaron y de 132 gramos en aquéllos sin complicaciones. En las dos niñas sometidas a esplenectomía antes de los seis meses de edad hubo complicaciones; una de ellas se debió a negligencia de los padres. En la esplenectomía electiva en pacientes con hemopatías deben ponderarse cuidadosamente los riesgos contra los beneficios en cada paciente

Normas para atendimento aos hemofílicos e portadores de coagulopatias congênitas / Rules for attending patients with hemophilia and congenital blood coagulation disorders

O objetivo primordial do trabalho foi dar as linhas gerais de diagnóstico e conduta frente às diversas intercorrências médicas, odontológicas, psico-sociais e fisioterápicas...